Attitudes Toward Menstrual Suppression Among Cyclic and Continuous Contraceptive Vaginal Ring Users in Kenya

Kristina Wilbekin Walker; Nelly Mugo; Kenneth Ngure; Stephen Gakuo; Edinah Casmir; Howard Wiener; Dustin Long; Sadeep Shrestha; Jeanne Marrazzo

doi:10.18502/jfrh.v17i3.13534

Attitudes Toward Menstrual Suppression Among Cyclic and Continuous Contraceptive Vaginal Ring Users in Kenya

J Family Reprod Health. 2023 Sep;17(3):118-127. doi: 10.18502/jfrh.v17i3.13534.

Authors

Kristina Wilbekin Walker¹, Nelly Mugo^{2

3}, Kenneth Ngure^{3

4}, Stephen Gakuo², Edinah Casmir², Howard Wiener¹, Dustin Long⁵, Sadeep Shrestha¹, Jeanne Marrazzo⁶

Affiliations

¹ Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
² Center for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya.
³ Department of Global Health, University of Washington, Seattle, WA, USA.
⁴ School of Public Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya.
⁵ Department of Biostatistics, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
⁶ Department of Infectious Diseases, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA.

Abstract

Objective: Multipurpose prevention technologies (MPTs) are developmental dual-purpose options that would provide women with a contraceptive as well as a prevention modality aimed at sexually transmitted infections. The contraceptive vaginal ring (CVR) has many properties that makes it an ideal MPT candidate. The objective of this study is to understand women's attitudes towards menstrual suppression, a potential side effect of using a CVR, and how to address these attitudes for MPT vaginal rings in development.

Materials and methods: We analyzed data derived from a subset of cohort study participants (n=45) in Thika, Kenya between January 2016- December 2018. The primary study enrolled 121 women 18-40 years with bacterial vaginosis and randomized them to cyclic or continuous CVR use for eight months. During the 6-month follow-up, a questionnaire eliciting attitudes towards menstrual suppression was administered. Responses to the menstrual suppression questionnaire between participants in the cyclic and continuous CVR use groups were compared. Likert-scale responses were summed to create a menstrual suppression attitude summary score, and a hierarchical cluster analysis was conducted to identify similarities in response patterns among all participants.

Results: Totally 81.8% of continuous CVR users believed that one was less likely to get pregnant after using hormonal medication to suppress menses, compared to 47.8% of cyclic CVR users (P=0.02), and were more worried it would cause long-term health effects (86.4% vs 60.9%, p = 0.05). The menstrual suppression attitude summary score ranged from 8 to 42, with lower scores indicating negative attitudes. The summary score identified three distinct clusters. When asked if menstrual suppression effects long-term health; 100% of Cluster 3 was worried compared to 80.8% of Cluster 2 and 46.2% of Cluster 1 (p = 0.03). The average summary score among Cluster 3 (Mean = 14.8, SD = 4.6) was lower (p < 0.001) and women were more worried about discomfort during sex (p=0.05) as well as their sexual partners feeling the ring (p=0.02).

Conclusion: Women are more likely to have negative attitudes if they believe menstrual suppression hinders future reproductive health. Education on cycle control and fertility could mitigate negative attitudes and improve uptake of CVRs.

Keywords: Contraceptive Vaginal Ring (CVR); HIV; Menstrual Suppression; Multipurpose Prevention Technologies.